Change in defense mechanisms during long-term dynamic psychotherapy and five-year outcome.

OBJECTIVE: Research suggests that defense mechanisms may underlie other aspects of functioning and psychiatric symptoms. The authors examined whether defenses change in accordance with the hierarchy of defense adaptation during long-term dynamic psychotherapy and whether such change is associated with long-term outcomes on other measures.
METHOD: Twenty-one adults with depressive, anxiety, and/or personality disorders entered long-term dynamic psychotherapy (mean=248 weeks) and subsequent follow-along (mean duration, 5.1 years). Measures of functioning and symptoms were gathered in periodic follow-along interviews, external to the therapy. A median of eight psychotherapy sessions over 2.5 years for each participant were rated using the Defense Mechanism Rating Scales quantitative method.
RESULTS: Overall, the lowest (action) and highest (high adaptive) defense levels in the hierarchy of defenses improved significantly, as did overall defensive functioning (median effect size=0.71, 95% CI=0.01-1.83). Overall defensive functioning still remained below the healthy-neurotic range. A higher number of axis I disorders and childhood histories of sexual abuse and witnessing violence were associated with a slower rate of improvement in defenses. Change in defenses within therapy by 2.5 years was highly associated with significant levels of change at 5 years in external measures of both functioning (rs=0.60) and symptoms (rs=0.58), controlling for initial levels.
CONCLUSIONS: Change in defensive functioning in long-term psychotherapy largely follows the hierarchy of defense adaptation. The relationship to long-term improvement in outcomes suggests that defenses be considered candidates for mediating improvement in functioning and symptoms.